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Measuring the Effectiveness of a Collaborative for Quality Improvement in Pediatric Asthma Care: Does Implementing the Chronic Care Model Improve Processes and Outcomes of Care?
Mangione-Smith R, Schonlau, M, Chan KS, Keesey J, Rosen M, Louis TA, Keeler EB, Ambulatory Pediatrics, 2005 5 75-82.

The Institute for Healthcare Improvement (IHI) breakthrough series collaboratives promote a method for inducing and sustaining organizational change based on: 1) explicit agreement on improvement goals, 2) monitoring ongoing progress through specific measures, 3) developing a menu of change ideas based on "best practices" for the disease, and 4) the Plan-Do-Study-Act (PDSA) approach to rapid-cycle process improvement. The collaborative approach to quality improvement has appealing face validity, but there are few controlled studies of its effectiveness.

Under funding from the Robert Wood Johnson Foundation, a multidisciplinary research team from RAND/UC Berkeley performed an evaluation of the organizational and patient-level impact of participation in a breakthrough series collaborative for asthma care in children and adolescents (referred to as children from here forward) in nine geographically dispersed health care organizations.

Between March 1, 2000 to March 1, 2001, the nine participating clinical sites sent representatives to attend four IHI collaborative sessions for asthma care. RAND began the evaluation of the asthma breakthrough series in March of 2001. As part of the evaluation, telephone surveys were administered to parents of asthmatic children aged 2-18 years and to asthmatic adolescents aged 12-18 years. These interviews assessed whether certain aspects of the breakthrough series had been implemented at the individual level and whether these changes in process of care for asthma influenced key health related outcomes. Medical records were also reviewed to examine processes of care for these children.

Pediatric general and asthma-specific quality of life were key outcomes of interest in this evaluation study. In collaboration with Dr. James Varni, a short-form of the PedsQL 4.0 was developed to assess both general health related quality of life (15 items) and asthma specific quality of life (22 items) in children 2-18 years old who either obtained asthma care at a breakthrough series (intervention) site or at a control site. The final study sample included 385 asthmatic children from 9 intervention sites and 126 asthmatic children from 4 control sites.

Adjusted results indicate significantly increased scores on the general PedsQL 4.0 short-form for children in the intervention sites compared to those obtaining care in control sites by 3.8 points (CI 0.7, 7.00) on a 0 to 100-point scale. Failure to receive appropriate asthma medications according to the child's level of disease severity decreased general health related quality of life (HRQOL) by 6.16 points (CI -9.6, -2.7). Inappropriate treatment of asthma also significantly decreased asthma-specific HRQOL for children by 9.8 points (CI -5.1, -14.6). Parents of younger children (aged 2-11) and adolescents reporting increased levels of self-efficacy had significantly increased asthma-specific HRQOL scores. Each point on the 4-point self-efficacy scale increased the asthma specific HRQOL score by 4.6 points (CI 2.0, 7.0).

This study represents one of the first controlled evaluations of a breakthrough series collaborative for children with asthma. The evaluation indicates that the collaborative was at least partially responsible for significantly higher ratings on general HRQOL in this population of asthmatic children.

Presented at the 2003 AcademyHealth meeting by: Rita Mangione-Smith, University of California, Los Angeles.